A nurse is assisting with the care of a preschooler who is immediately postoperative following a tonsillectomy. Which of the following actions should the nurse take?
Apply an ice collar.
Encourage the child to use a straw.
Remind the child to cough and deep breathe.
Provide cherry fruit juice.
The Correct Answer is A
A. Applying an ice collar helps reduce swelling and discomfort in the throat after a tonsillectomy. Cold therapy is effective in the early postoperative period to minimize bleeding and pain.
B. Using a straw should be avoided after a tonsillectomy because it may cause trauma to the surgical site and increase the risk of bleeding.
C. Coughing and deep breathing should be avoided after a tonsillectomy as they can cause irritation or dislodge the blood clots in the surgical site, leading to bleeding.
D. Providing cherry fruit juice is not ideal, as acidic or red-colored liquids can irritate the throat and may make it difficult to monitor for post-operative bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Crushing sustained-release tablets is not recommended because it can alter the medication's intended effect, releasing it all at once, which can be dangerous for the child.
B. Allowing medications to flow into the tube by gravity is the correct method. It ensures the medication is delivered slowly and effectively, preventing the tube from clogging and ensuring proper absorption.
C. Flushing the tube with 2 mL of sterile water is insufficient after all medications are administered. Typically, the tube should be flushed with 15-30 mL of water before and after medication administration to ensure patency.
D. Mixing all medications together is not recommended because different medications may have incompatible properties, and mixing them could alter their effectiveness or cause adverse reactions. Each medication should be administered separately.
Correct Answer is C
Explanation
A. Massaging the injection site is not recommended, as it can cause irritation or tissue damage, especially after certain types of injections.
B. The dorsogluteal muscle is no longer recommended for vaccine administration due to the risk of injury to the sciatic nerve. The preferred site is the vastus lateralis or deltoid muscle.
C. It is essential to ensure that the guardian has signed an informed consent form prior to administering the vaccine. This confirms that the guardian is aware of the vaccine's benefits and potential risks.
D. Aspirating for blood return before administering vaccines is no longer recommended or necessary for intramuscular injections.
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